neck and low back pain

Regional syndromes-Neck and low back pain

Neck pain

Cervicalgia the importance of the problem

Cervicalgia (pain in the cervical region) is very common in clinical practice.

The annual incidence of neck pain is 15%.

Woman complaint more often of neck pain and have a higher risk to develop chronic cervicalgia than men.

Young people are often affected by episodes of acute neck pain, which are usually transient.

The most common condition is chronic pain with acute, recurring episodes in adults and the elderly

Functional anatomyAtlasAxis

The structure of vertebraeA Vertebral bodyB Vertebral diskC Facet jointD Intervertebral foraminaE Spinal cord and nerve rootshttp://www.neurospineinstitute.org/procedures/spine-anatomy-physiology/

Functional anatomy- nerve rootsNerve roots exitsC1C2C4C3C5C6C7C8Sensory territory of nerve roots dermatomes

Common causes of neck pain

Trauma- History of trauma- Occupational factors, bad posture Often causes acute attacks in young people Diagnostic tests usually normalSpondyloarthrosis Pain usually mechanical- Chronic or recurring pain- Can be associated with neurogenic manifestations, arising from the nerve roots or spinal cord The most common cause of neck pain in adults and the elderly Suggestive x-ray featuresInflammatory joint disease Pain tends to be inflammatory- Usual association of manifestations of arthritis in other locations Rheumatoid arthritis, seronegative spondyloarthropathies and juvenile idiopathic arthritis often affect the cervical spineInfection Acute or chronic infections of the vertebral bones or disks, like tuberculosis or brucellosis, may, on rare occasions, affect the neckMetastases Tumors in the thyroid, lung, breast, kidney and prostate may metastasize to the cervical spine- Multiple myeloma can affect this region- Primary bone tumors are rareReferred painSpecial attention to the shoulder, pulmonary vertex and heart

Risk factors

Age is an important factor when identifying the cause of cervicalgia

Risk factors

http://www.activecarewilm.com/2012/05/23/poor-posture/

Clinical case 1Maria was 68 years old. She was a housewife and farm worker. She went to the doctor because of pain affecting the cervical and upper thoracic region. The pain had begun insidiously when she was about 40 and had been getting progressively worse. In the first years of the disease, the pain appeared occasionally at times of strenuous physical work. As the years went by, it became more frequent and appeared with less and less effort until it was almost constant, with flares. During such exacerbations, which lasted up to a week, the pain extended to the whole cervical area, and also involved the shoulders. The pain was worse with exercise (such as carrying heavy items in her arms) and was relieved by rest. She had no pain at night except when she moved in bed. She takes NSAIDs, with inconsistent effect. When asked, she described occasional pain and tiredness in her arms but denied any paresthesia or weakness. The pain was not exacerbated by Valsavas maneuver. Maria also had similar pain in the lumbar region and in her knees. She had a history of peptic ulcer and arterial hypertension (under control with Prestarium and Tertensif).

Taking historyWhat kind of pain?

A history of recent trauma or the appearance of pain as a result of a prolonged, forced position acute cervicalgia

An inflammatory rhythm - infection, inflammation or neoplasm.It is important to look for symptoms and signs of arthritis in other locations. The systematic enquiry will try to identify signs of systemic disease

Mecanical pain spondyloarthrosis

Real neurogenic pain - root compressionintense, dysesthesic (electric shock or pins and needles) and follows a dermatome distribution

Taking history

The location of the pain gives an indication of its most likely point of originWhere is the pain localized?

Regional clinical examinationObservation Accentuation or attenuation of physiological lordosis, localized kyphosis, scoliosisAtrophy of the shoulder musclesLocalized swelling

PalpationNonspecific should be interpreted with cautionMuscle spasm associated with a stiffness! Pain that is clearly located over one or two spinous processes may suggest infection or neoplasm.

Regional clinical examination

Mobilization

Amplitude of movement varies considerably from one person to another. Measurements of the range of movement tend to be qualitative, looking for a significant reduction in mobility associated with functional impact and local pain, or for pain radiating with movement

Physical examinationH = 155 cm, W = 80 kgReduced lateral inclination and rotation of the neck, with pain at the extremes of movement.Pain on palpation of different muscular points on the posterior and lateral aspects of the neckNormal power, reflexes and pain sensation.No muscle atrophy.

What is the probable diagnose?

Cervicobrachial neuralgia

Nonspecific chronic cervicalgia

Cervical disk herniation

What diagnostic tests would you request?

Lateral x-ray of the cervical spine

CT

MRI

Lateral x-ray of the cervical spineReduction in the intervertebral space Scleroza platoului vertebral Sclerosis of the vertebral endplatesOsteophytes

114222333

TreatmentNonfarmacological treatment encourage her to stay active - regular relaxation exercises, mobilizing and stretching the musclesavoid strenuous activities that put a strain on her neck, such as carrying heavy loads and effort in forced positions.Progressive loss of weighA low, well-adjusted pillowPhysiotherapy Local heat applied at home during exacerbationsThe cervical collar, properly adjusted that it is comfortable but effective

MedicationNSAIDs - COX2 selective (Celecoxib or Etoricoxib)Analgesics (Paracetamol +/- Codeine or Tramadol)Myorelaxants

CHRONIC NON-SPECIFIC NECK PAINMAIN POINTSThis is a very common condition in the elderly.The pain is usually insidious and chronic, with exacerbations. It may also involve the scapular region though it has no neurogenic characteristics.Neck movements are limited (especially rotation and lateral inclination).Spondyloarthrosis is the most common underlying cause, but the correlation between x-ray and clinical examination is very unreliable. !Investigation should be limited to the essential cervical x-ray maybe (NO need to repeat them often)

Treatment is conservative.Avoidance of excessive effort should be combined with a program of regular mobilization and relaxation exercisesAnalgesics, mild anti-inflammatories and muscle relaxants may be necessary during flare-upsPrognosis varies but the pain tends to become chronical.

Clinical case 1 - evolutionDuring 3 years of follow-up, Maria, our previous patient, was very pleased with her response to treatment. Although she still had some pain, it was more tolerable. Exacerbations were now rare and related to effort.This time, she came back to us because of exacerbation of the pain, which was no longer responding to the usual measures. The pain was particularly intense and involved the left arm and forearm as far as the thumb. She described this radiated pain as an electric shock and had noticed that it appeared especially when she turned her neck to the right. A slight cough that she had had for a few days made the pain unbearable, as it increased the radiated pain, causing the pins and needles to last longer.

Taking history

Where is the pain localized?

Regional physical examinationCervical Lasgue testForced lateral flexion of the neck to the right caused the pain to radiate to the lateral aspect of the left forearmSpurlings maneuver Vertical compression of the head towards the neck caused local pain without radiation

Regional physical examination- neurological examinationIf we suspect root or spinal cord compression, a detailed neurological examination of the upper limbs is called for. Evaluation of touch and pin-prick sensation will follow the dermatomes Muscle strength and reflexes can be assessed as shown in table

Nerve rootMuscle strength Abnormal OT ReflexesC5Shoulder - abductionBiceps reflexC6Wrist- extension,Elbow- supination, flexionRadial reflexC7Elbow - extension,Wrist flexionTriceps reflexC8Fingers - flexionNA

Local examinationThe pain worsened during active and passive mobilization of the neck, which was more limited, with associated muscle spasm.

Forced lateral flexion of the neck to the right (cervical Lasgue) caused the pain to radiate to the lateral aspect the left forearm

Neurological examination showed reduced pin-prick sensation over the thumb and radial side of the left forearm;

There were no apparent changes in muscle strength. Tinels and Phalens signs for carpal tunnel syndrome were negative

What is the probable diagnose?

1. Nonspecific chronic cervicalgia

2. Cervico-brachial neuralgia (Cervical nerve root compression)

3. Cervical spondylodiscitis

InvestigationsCervical radiographyIt enables us to discover the cause of nerve root compression: spondylarthrosis, spondylolistheses, destructive lesions of the vertebrae

MRI of cervical spineThe most accurate examination for nerve root compressionAre indicated only if surgery is contemplated

CT myelography Recommended for those with pacemaker or surgical devices in the cervical region

Electromyogram of upper limbsCan be decisive in the case of inconclusive abnormalities in the neurological examination as it clarifies the existence of and aids in the location of lesions.

MRI in compression nerve root syndrome T2-weighted MRI in a patient with right-sided C6 radiculopathy.A. Sagittal view showing spondylosis at C5-C6 and C6-C7 disk levels (ARROWS)B. Axial view showing a right-sided disk-osteophyte complex at C5-C6 disk level (ARROW) that is putting pressure on the C6 nerve root.

TreatmentConservative treatmentCervical collarPhysical therapy for muscle relaxation treatment and careful traction of the cervical spine after flare-upPhysiotherapyNSAIDs, analgesics, muscle relaxantsEpidural steroid infiltration (CT guided) Surgical treatmentIf symptoms persist > 6 weeks or worsen (especially neurological) despite conservative treatment neurosurgical assessment

CERVICAL NERVE ROOT COMPRESSIONMAIN POINTSCervical nerve root compression should be suspected whenever there is dysesthesic pain in the territory of a root and exacerbated by cervical movements. Sensory or motor deficiencies may ensue.

The roots C5C7 are most often affected.

Root compression may accompany the onset of cervical pain, especially in young people, suggesting a disk lesion, or develop insidiously in the presence of a chronic degenerative condition such as spondyloarthropathy.

Lasgues cervical maneuver, Spurlings maneuver and a neurological examination of the upper limbs are the key to the diagnosis.

Electromyography and MRI (Magnetic Resonance Imaging) may be indicated when the persistence or severity of the situation may warrant surgery.The prognosis is usually favorable with conservative treatment.

The persistence of incapacitating symptoms or progressive neurological alterations >6 weeks in spite of appropriate conservative treatment may justify assessment by an experienced surgeon.

Clinical case 2Ana, 49 years old, is being followed up at the Rheumatology Clinic Cluj Napoca for rheumatoid arthritis that had begun 10 years before. Is being treated with Methotrexate and NSAIDs with highly satisfactory results on her peripheral arthritis.

She complaint of neck pain for the first time. She put it down to working long hours at the computer and some stress. A more detailed enquiry revealed that the pain was in the upper cervical area and sometimes involved the occipital region. It got worse in the last 2 weeks. It was worse at the end of the working day and didnt improve with rest. The pain was there when she woke up, and she experienced moderate morning stiffness of the neck lasting for about 2 hours. She denied any neurogenic manifestations in the upper limbs or her body.Our examination revealed painful restriction of neck movements, but neurological examination was normal.

Biologic: VSH = 20-40 mm/h, CRP = 1,2 mg/dl

What diagnostic tests would you request?

None

Antero-posterior x-ray of cervical spine

Dynamic lateral view x-ray of cervical spine (flexion and extension)

Anterior atlantoaxial subluxation in rheumatoid artrhritisAnterior atlantoaxial subluxation the distance between the posterior edge of the arch of the atlas and the anterior edge of the odontoid process during flexion>5 mmAs a result of rupture or distension of the transverse and cruciate ligaments of atlas (due to chronic inflammation of atlantoaxoidian joit).

INFLAMMATORY NECK PAINMAIN POINTSThe possibility of cervical involvement should always be borne in mind and actively investigated in patients with rheumatoid arthritis, juvenile idiopathic arthritis and seronegative spondylarthropathy. On rare occasions, cervical involvement may be the first manifestation of these diseases.

Infections of the cervical vertebrae and disks (spondylodiscitis) are relatively rare but should always be considered, especially in a clinical context suggesting tuberculosis or brucellosis.

Pain of metastatic origin may have an inflammatory rhythm, although it tends to be more constant and unrelated to movement or rest.

First line investigations: X-rays and acute-phase reactants measured together with tests specific to the clinically suspected causes.

A referral to a specialist- Who ? Where? When? -Almost all cases of neck pain should be managed by general practitioners

A referral to a specialist- Who ? Where? When? -Some situations justify sending patients to a specialist (rheumatologist, orthopedic surgeon, neurosurgeon, physiatrist or even a specialist in internal medicine, as the case may be):

Reason to suspect an infectious or neoplastic lesionNeck pain as part of polyarthritisManifest cervical instability or deviationNeurological signs in the nerve roots or spinal cordIntense symptoms that are resistant to conservative treatment

Durerea lombar

Durerea lombar Importana problemeiPrevalena anual a durerii lombare n SUA 15-20%

Este cea mai frecvent cauz de impoten functional la pacienii < 45 ani i cea mai frecvent cauz de disabilitate n SUA

85% din populaie va avea cel puin o dat n via experiena unei dureri lombare

Este a doua cauz ca frecven de adresabilitate n cabinetul medicului de familie

90% din durerile lombare se amelioreaz i trec n 2 - 6 sptmni, mai ales dac pacienii rmn activi

Recurena este frecvent: 60-80% din pacieni au recidive n urmtorii 2 ani

Anatomie funcionala

Anatomie funcionalaEmergena rdcinilor nervoase lombareStnga: compresiune rdcin nervoas prin hernie de disc sau osteofit al articulaiei interfaetare

Prezentare caz 1Teodora, femeie de 35 ani care lucreaz la grdini, are durere de spate de intensitate mare de 3 zile de cand s-a aplecat s ridice un copil. A mai avut intermitent dureri de spate mai ales la sfritul zilei, dupa ce fcea efort mai mare ridicnd copii i material didactic, dar niciodat durerea nu a avut aceast intensitate.

A folosit un unguent antiinflamator i a luat ibuprofen (Nurofen) 200 mg o dat pe zi fr ameliorare.

Ce informaii anamnestice suplimentare v sunt necesare ?

Informaii despre caracterul durerii

Informaii despre semnele neurologice i/sau iradierea n membre (un membru sau ambele in bascul)

Toate cele de mai sus i alte elemente...

Elemente cheie din anamnezDurere: localizare, iradiere, caracter (arsur, amoreal, etc), debut, durat orar (constant/intermitent), severitate, factori declanatori (traumatisme, poziie, miscri, repaus, etc) si factori de ameliorare

Semne neurologice: parestezii, hipo/hiperestezie, senzaie de greutate n membru, parez/plegie, tulburri motorii (de mers), tulburri sfincteriene, etc.

Semne generale: febr, scdere ponderal, frisoane, astenie, etc.

Boli asociate/traumatisme: neoplasme, TBC sau contaci, alte infecii, boli arteriale periferice, traumatisme majore sau mici etc

Condiii de via i munc: profesie, domiciliu, lifestyle, toxice, situaie familial, etc

Factori clinici sugestivipentru existena unei patologii serioaseVrsta < 20 ani sau > 50 de aniDurerea nocturn i de repaus, progresivSimptome/semne generale: febr, frisoane, semne infecioase, sindrom impregnare malign - scdere ponderal, manifestri de organTraumatism/infecie recentIstoric cancer, osteoporoz, corticoterapieSemne neurologice: semne de compresiune, iradiere n membrele inferioare bilateral sau in bascul, modificri ROT, parestezii, pareze, anestezie n a, retenie urinar

Prezentarea cazului - completare Durerea se accentueaz la efort i cedeaz la repaus Nu are iradiere n membrul inferior Nu are accentuare la tuse sau strnut, nu are parestezii sau tulburri de miciune Nu are semne generale (febr, astenie, sindrom impregnare malign) Nu a avut nici un traumatism A mai avut durere lombar moderat (jen sau disconfort), dar niciodat de aceast intensitate St mult aezat, dar i n picioare; car i mut greuti: cri, cataloage, plane; conduce mult (face naveta); este n general sedentar (nu face miscare, exerciiu fizic, etc)Este activ, vesel, sociabil, mulumit de viaa, familia i profesia ei

Ce vei cuta n primul rnd la examenul obiectiv general ?

Tulburrile de postur i atitudine

Tulburrile de mers

Semnele generale

Elemente cheie din examenul obiectivExamen coloan vertebral: Postura, inspecia (curburi fiziologice/ patologice) Palparea i percuia pentru identificarea punctelor dureroase i contracturilor musculare Mobilitatea coloanei vertebrale: toate direciile, toate poziiile Mersul: antalgic, clcie, vrfuri Semnele de iritaie radicular: testul Lasegue

Examen neurologic: mers, ROT, hipo/hiperestezie, fora muscular, hipotrofie muscular, etc

Examen general

Examen obiectiv = 180 cm, G = 85 kgMers clcie i vrfuri posibil (semnul talonului i poantei negativ)Contractur muscular paravertebral importantDurere moderat la flexia anterioar a trunchiului la aprox 800, fr durere la percuia SI i manevre pentru SI negativeSchber = 2 cmLasegue negativROT simetrice, prezente bilateral, far tulburri de sensibilitateFor muscular pstrat la toate grupurile musculare, fr hipotrofie muscular

Ce diagnostic vei formula ?

Lumbago acut hiperalgic

Lumbago subacut

Lombalgie cronic recurent

Clasificare criterii de evolutie

Ce interpretare clinic avei n aceast etap ?

Hernie de disc

Lombalgie comun (nespecific)

Osteoporoz cu tasari vertebrale

Lombalgie acut - cauzeMecanice deranjamente minore n disc, platouri vertebrale, articulaiile faetelor, ligamente, fascii, muchi paravertebrali, vase - nespecifice ! artroz - spondilartroz, discartroz, hernie de disc, stenoz spinala, spondilolisteza, tulburari de static vertebralBoli infecioaseosteomielit, spondilodiscit, sacroiliit infectioas, herpes zoster, etc. Boli neoplazice/infiltrativeosteom osteoid, osteoblastom, osteocondrom, metastaze osoaseReumatisme inflamatoriispondilita anchilozant, SpABoli endocrineosteomalacie, osteoporozDureri iradiate abdominale, pelviene, toracice anevrism aort abdominal, afeciuni gastroIS, endometrioz, boal inflamatoare pelvin, etc

10 %

BoalaVrstaL0calizarea dureriiCalitatea dureriiAgravare/ameliorareSemneDeranjamente minore20-40lombar, fese, reg. post. coapsesurd,spasm activitatea, flexia mobilitate, sensibilitate +Hernie de disc30-50lombar,iradiere n membruascuit, arsur, parestezii ortostatism flexie, ezutLasegue + F muscROT asimetriceSpondilartrozaStenoza spinal> 50lombar, iradiere membre bilat.surd, ascuit parestezii mers extensie+/- F muscROT asimetriceSpondilita anchilozant15-40lombar, art. SIprofund repaus activitatearedoare mobilitatesensibilitate + art. SIInfecie oricarelombar, sacrusurd, ascuitvariabilifebr sensibilitate ++/- tulb. neurolCancer> 50osul afectatprofund, persistent, progresiv decubit, tusesensibilitate ++/- tulb. neurol+/- febr

Clasificare criterii clinice

Ce investigaii vei solicita ?

Nici una

Radiografie lombar (anteroposterioar + laterolateral)

Alte investigaii: RMN

Radiografia n lombalgia comun Rol imagistic diagnostic in durerea lombar ncurajarea pacientului c patologia serioas este absent !!! Etiologia durerii nu poate fi determinat prin radiografie lombar la majoritatea pacienilor Expunerea nenecesar la radiaii ionizante radiografie lombar (AP+LL) face ct un Rx toracic zilnic timp de 4 ani Radiografia lombar asociat cu satisfacia pacientului Studiu RCT 421 pacieni cu durere lombar cu o durat medie de 10 sptamani 80% ar fi preferat s faca o radiografie lombar dac li s-ar fi dat ocazia sa aleagFr diferen semnificativ n evoluia i tratamentul pacienilor care au fcut radiografia i cei care nu a fcut Nu

Rezonana Magnetic Nuclear n lombalgia comun Pacieni asimptomatici - RMN cu hernii de disc, protruzii, prolabri i degenerri discale Studiu RMN - 98 indivizi asimptomatici 38% anomalii a mai mult de un disc intervertebral52% prolabri discale, 27% protruzii discale, hernii discale 1%

Alt studiu 67 indivizi nu au avut niciodat durere 57 % au o anomalie RMN, inclusiv hernii de disc 36 % si stenoza spinal 21% .Anomaliile detectate coincidene, nelegate de durerea actualTeste imagistice precoce concluzii greite, intervenii nenecesare, prognostic prost !! Nu

Date of download: 8/8/2012Copyright The American College of Physicians. All rights reserved.From: Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of PhysiciansAnn Intern Med. 2011;154(3):181-189. doi:10.1059/0003-4819-154-3-201102010-00008Results From Meta-analysis of Randomized, Controlled Trials of Routine Imaging Versus Usual Care Without Routine ImagingFigure Legend:

Medical societies list 45 dubious tests, therapies (compendium of 45 clinical donts)April 4, 2012 Robert LowesDo not obtain imaging studies in patients with nonspecific low back pain !! Do not obtain a preoperative chest X ray when lacking any clinical suspicion of intrathoracic pathology Do not order a stress test for asymptomatic patients who are at low risk for coronary heart disease Do not order RF and AAN in asymptomatic patients

Factori de alarm (red flags) care indic necesitatea unor investigaii suplimentare

Factori de alarm (red flags)Cauza posibilInvestigaiiVrsta > 50 aniIstoric de cancerDurere nocturn progresivScdere n greutate neexplicatCancerRMNRadiografie LSTCVSHVrsta > 50 aniIstoric de osteoporozCorticoterapieTasare vertebralRadiografie LSTCFebraInfecie recentConsumator droguri ivSpondilodiscitaRMNVSH/CRP

Deficite neurologice la multiple sediiAnestezie n aRetenie urinar/incontinen fecalSindrom de coad de calRMNDurere iradiat n membru, cu distribuie dermatomeric L4, L5, S1, cu durata > 1 lunDeficit motor semnificativ/progresivHernie de disc RMNEMG/VCNDurere lombar joas inflamatoareVrsta < 45 aniSpondilita anchilozantaRMN art. SIRadiografie bazinVSH/CRP/HLA B27

Care sunt principalii factorii de risc pentru cronicizarea lombalgiei ?

Factori psihologici

Factori sociali

Factori anatomici

Factori de risc pentru cronicizare (yellow flags)

Categorii factori de risc cronicizareFactori risc cronicizare (yellow flags)Sistem de credineComportament de evitare a activitilor de teama dureriiExpectana intensificrii durerii n momentul reintoarcerii la muncGndire de tip catastrofic centrarea excesiv pe durere , sentimentul lipsei de control asupra durerii Atitudine pasiv n cadrul terapiei de recuperareFactori afectiviIstoric profesional negativ - mediu de lucru nesuportivNoncomplian la kinetoterapieEvitarea activitilor zilnice Istoric de dependen medicamentoasAnxietateDepresieIritabilitateComorbiditiIstoric de boli cu disabilitateSomn perturbat de dureriSemne lombalgie nonorganic (semnele lui Waddell)Dureri la teste de ncrcare axialSensibilitate nonanatomic/superficialExagerarea durerii n cursul examenului fizicTest Lasegue ameliorat daca pacientului i se distrage atentiaSlbiciune muscular sau tulburari de sensibilitate cu distribuie regional

Criterii psihosociale care indic risc de cronicizare (yellow flags)

ntrebriIndicatori de prognostic negativ (yellow flags)Ai mai avut concediu medical pentru durere de spate ?DaCare credei c este cauza durerii de spate ?Focus pe leziunea structuralAtitudine pesimist sau catastroficCe credei c v-ar putea ajuta?NimicAlii, doctorii, nu pacientulCum reacioneaz ceilali la durerea de spate ?OstiliSuperprotectiviCe facei ca s ameliorai durerea ?Atitudini pasive: repaus, evitare activiti fiziceCredei c vei mai putea lucra ? Peste ct timp ?Nu sau nu tiu

Durerea lombar nespecific - tratament

Durere lombara joas Acut Subacut sau cronicDurata< 4 sptmni> 4 sptmniMenine activitateEducaieAplicaii caldeAcetaminofenAINSRelaxant muscularAntidepresive tricicliceBenzodiazepineAntiepilepticeTramadol/OpioideManipularea coloaneiKinetoterapieMasajAcupuncturYogaTerapie cognitiv comportamentalRelaxareReabilitare intens. interdisciplinar

Educaia pacientului

Durerea lombar nespecific Algoritm de tratament Meninerea activitii fizice n limita toleranei la durere

Educaia pacientuluiRepausul la patdoar n cazuri individualeDLN acutDLN cronicAnalgezieParacetamol +/- CodeinAINS- Tradiionale +/- IPP- Inhibitori selectivi COX2 MiorelaxanteAntidepresiveOpioideProceduri fizicale, masaj, manipulri, acupunctura Se pot asociaGhid de practic pentru medicii de familie

Factori care influeneaz alegerea medicaieiDurata simptomelorSeveritatea simptomelorBeneficiile ateptateRspunsul anterior la terapieReaciile adverse anterioareComorbiditile

Prezentare caz 2 Marius, brbat de 48 ani care lucreaz ca i grdinar la un centru de gradinrit, prezint de 3 sptmni durere lombara cu iradiere n membrul inferior stng (pn la degetul mare) cu amoreli i parestezii pe faa posterioar a membrului i imposibilitatea mersului pe vrfuri (semnul poantei).

A luat Diclofenac 150mg/zi i Mydocalm 150mg/zi, fr ameliorare, ba chiar chioptarea i amoreala s-au accentuat.

Ce interpretare clinic avei n aceast etap ?

Hernie de disc

Lumbago acut nespecific /lombalgie comun

Spondilit anchilozant

LombosciaticaLombosciatica = durere lombar cu iradiere n membrul inferior (cu distribuie dermatomeric) nsoit de simptome neurologice (ex. parestezii, deficit motor).

Cauze n 90% din cazuri este cauzat de o hernie de disc.Alte cauze posibile: stenoza de canal lombar, chisturi i tumori.

Diagnosticn prinicipal se bazeaz pe anamnez i examen clinic !

Caracteristicile lombosciaticiiDurerea unilateral n membrul inferior > durerea lombar

Durerea iradiaz mai jos de genunchi n picior i degete

Parestezii, amoreali cu acceai distribuie ca i durerea

Testul Lasgue pozitiv (durere mai intens n membrul inferior)

Teste neurologice pozitive deficit motor, modificri de reflexe

Monitorizarea pacientului cu lombosciatic

! Reevaluare clinic dup 4-6 sptmni de tratament conservatorEducaia pacientuluiEec la terapia conservatoare: RMN ? DA - la pacienii cu simptome severe care nu rspund la tratament conservator n 6-8 sptmni

Intervenia chirurgical?La pacienii cu simptome severe la care exist o concordan ntre manifestrile clinice i imagistic.!! Aspect imagistic de HD poate aprea la 20-36% din subiecii fr simptomeDetermin o ameliorare mai rapid a simptomelor, dect tratamentul conservator la unii pacieni cu lombosciaticTratamentul conservator i terapia chirurgical au rezultate similare la 1 an


Nici una

Radiografie lombar (anteroposterioar + laterolateral)

RMN coloan lombar

Rezonana Magnetic Nuclear n lombosciaticRMN lombosacrat se recomand la pacienii cu:Lombalgie acut la prezentare, dac exist semne de deficit neurologic sever

Lombalgie persistent cu semne de compresie radicular care sunt candidai pentru intervenie chirurgical

Da

Lombosciatica- tratament

Modaliti terapeutice ObservaiiMenine activitateaS rmn activiEducaia pacientuluiS neleag cauzele sciaticii, c nu sunt necesare investigaii n absena semnalelor de alarm, prognosticulFiziokinetoterapie+/-Acetaminofen +/- Opiode slabeLa nevoieAINSLa pacienii cu rspuns insuficient la paracetamolRelaxant muscularLa unii pacieni, de regul n asociere cu antialgice i/sau AINSAntidepresive tricicliceLa unii pacieni cu lombosciatic cronicEfect de scurt durat la unii pacieniLa unii pacieni cu lombosciatic cronicTramadol/Opioide puterniceLa pacienii cu dureri mari, durat scurt

Infiltraii epidurale cu corticosteroiziEfect de scurt durat la unii pacieniTratament chirurgicalLa pacienii cu simptome severe care persist peste 6-8 sptmni i la cei cu complicaii neurologice

Consulturi de specialitate - Cine ? Unde ? Cnd? -+

Durerea lombar nespecific- Cine ? Unde ? Cnd? -Medicul de familie+/- Kinetoterapeut i/sau Balneofizioterapeut

Durerea lombar cu red flags- Cine ? Unde ? Cnd? -Trimitere la specialist

Lombosciatica- Cine ? Unde ? Cnd? -Lombosciatic cu Durere sever non-responsiv la opioizi Deficit motor progresivSindrom de coad de cal

Lombosciatic acut (4-8 sptmni)

Lombosciatic subacut/cronic (> 8 sptmni)

NeurochirurgMedic de familieBalneofizioterapeutBalneofizioterapeutReumatologNeurochirurg

Prezentare caz 3 Andrei, brbat de 35 ani, prezint durere lombar joas de aproximativ 6 luni. Durerea este predominant dimineaa la trezire, l ine cam 1 or i cedeaz cnd ncepe s mearg. Este electrician la Electrica SA (poate urca pe stlpi). Uneori dimineaa abia se poate ridica din pat sau mbrca. n unele nopi, l trezete durerea, n altele nu are nimic.

Dac ia Ketonal nu mai are nici un fel de probleme.

Debut la adultul tnrSe instaleaz treptat (n zile, sptmni)Are evoluie cronic (durata > 3 luni)Se amelioreaz dup exerciiiNu se amelioreaz la repaus Trezirea n a doua parte a nopii din cauza durerii de spatePoate determina redoare matinal cu durata de >30 minuteDurere fesier alternant stnga-dreapta (datorat sacroiliitei)Iradierea caracteristic a durerii lombare din sacroiliit este n fes sau coapsa posterioar, adesea alternativ, de o parte i alta pseudo-sciatica nalt, basculant

Lombalgia inflamatoare - caracteristici

Lombalgia inflamatoare este simptomul cheie n spondilita anchilozant (SA)4 din 5Debut insidiosVrsta de debut 30 minuteAmeliorarea lombalgiei dup exerciiiTrezirea n a doua parte a nopii din cauza durerii de spateDurere fesier alternant1Rudwaleit M, et al. Arthritis Rheum. 2006;54:569-578; 2Calin A, et al. JAMA. 1977;237:2613-2614. Setul iniial de criterii2Criteriile recente1 Specificitate/sensibilitate: 70%80%Se aplic pacienilor < 50 ani cu durere > 3 luni

Manifestri musculo-scheletale axialeDurere inflamatorie la nivelul scheletului axialDebuteaz la articulaiile sacroiliace Coloana vertebral poate fi afectat la orice nivel

Artrite la nivelul oldurilor (coxita) i umerilor

Dureri ale peretelui toracic anterior prin afectarea articulaiilor sternoclaviculare i entezelor costosternale

Examen obiectivTeste de sensibilitate a articulaiilor sacroiliace1. Testul compresiei antero-posterioare a pelvisului 2. Manevra Gaensslen3. Manevra Patrick sau FABERE (hip flexion, abduction, external rotation, and extension)4. Testul compresiei laterale a pelvisului

Examen obiectivSA limiteaz mobilitatea coloanei vertebrale

Manifestri clinice n spondilartriteManifestri musculo-scheletale

Manifestri extra-articulare


Nici una

Radiografie standard

RMN

Rezonana Magnetic Nuclear n SA RMN art. sacroiliace cea mai sensibil metod pentru evidenierea leziunilor inflamatorii precoce

Leziuni inflamatorii active (STIR/T1 post-gadolinium)Edem osos (osteita) specificitate inalta pentru SACapsulitaEntezitaSinovita

Sieper J, et al. Ann Rheum Dis. 2005;64:659-663; Rudwaleit M, et al. Arthritis Rheum. 2005;52:1000-1008; Sieper J et al. Ann Rheum Dis. 2009; 68(Suppl II):ii1-ii44. Sacroiliit incipient, STIR

RMN coloan vertebralSe poate efectua un bilan al leziunilor inflamatorii spinale

Contribuie la diagnosticul precoce al SA

Are rol n evaluarea activitii bolii la pacienii cu SA definit

Examenul radiologic - sacroiliitaSacroiliita radiologic este trstura caracteristic a SA

CaracteristiciBilateral i simetric, predomin pe versantul iliac SAUnilateral sau asimetric artrita psoriazic, artrita reactiv

Radiografia art. sacroiliace poate fi negativ n stadiile precoce de boal !

Progresia radiologic a sacroiliitei

Examenul radiologic spondilitaModificri caracteristice n SA:Osteitaeroziuni anterioare - vertebra ptrat (leziunile lui Romanus) scleroz osoas reactiv -vertebra cu colurile luminoase (shiny corner)

Sindesmofitozaproces de neoformare osoas - trstura distinctiv a SA coloana de bambus n stadiile avansateRadiografia standard este cea mai important metod pentru detectarea i monitorizarea leziunilor structurale (ex.procesele de neoformare osoas).

ntrziere n diagnosticul SAFeldtkeller E et al. Rheumatol Int 2003;23:6166Sengupta R & Stone MA. Nat Clin Pract Rheumatol 2007;3:496-503ntrzierea diagnosticului 9 ani

Spondilartrita axialLombalgie inflamatoareStadiul 1Stadiul 2Stadiul 3Sacroiliit - RMNSacroiliit - radiologicSindesmofite - radiologicSpA nedifereniatSpA nedifereniat axialSA non-radiologicSpondilit - RMNSpondilit anchilozantSieper J, et al. Ann Rheum Dis. 2009;68(suppl II):ii1-ii44.

Criteriile ASAS de clasificare a SpA axiale(Ankylosing Spondylitis Assessment Study Group) La pacieni cu durere lombar >3 luni i vrsta de debut < 45 aniSacroiliita pozitiv imagisticinflamaie activ la examenul RMN, nalt sugestiv pentru sacroiliita asociat SpA

sacroiliit definit radiologic conform criteriilor New York modificate

Manifestri de SpA lombalgie inflamatoare artrit entezit (calcanean) dactilit psoriazis Crohn/colit rspuns bun la AINS istoric familial de SpA proteina C-reactiv

sauRudwailet M et al. Ann Rheum Dis 2009;68:777-783

Sacroiliit dg. imagisticplus> 1 manifestare de SpA

HLA B27plus> 2 manifestri de SpA

Zochling J, et al. Ann Rheum Dis. 2006;65:442-452Recomendarile ASAS/EULAR pentru tratamentul SA ASAS = Asessment of AS International SocietyEULAR = European League Against Rheumatism

Educaia pacientului

Lombalgia inflamatoare- Cine ? Unde ? Cnd?

Prezentare caz 4 Doamna Ileana, n vrst de 76 ani, prezint durere lombar inalt, brusc instalat n urm cu o zi, dup ce a ridicat o oal plin cu sup. Durerea este violent, nu o las s se mite, se accentueaz la micare i ortostatism. A mai avut neplceri la spate, dar niciodat aa ceva. Are menopauz de la 40 de ani (histerectomie total cu anexectomie), a avut o urticarie cronic pentru care a primit de repetate ori cortizon i are = 148 cm i G = 45 kg. Este fumatoare. A luat antialgice (paracetamol), durerea nu s-a ameliorat.


Nici una

Radiografie dorso-lombar (anteroposterioar + laterolateral)

Tomografie computerizat

Imagistica n tasrile vertebrale Radiografia de coloan vertebral se recomanda dac exist suspiciune de tasare vertebral pe fond osteoporotic

Tomografia computerizat se recomand dac exist traumatism n antecedente sau suspiciune de tasare patologic

Rezonana Magnetic Nuclear n tasrile vertebraleFracturi patologice maligneTasare benign

Prezentare caz 5M.P., 38 ani, prezint din iulie-august 2013 durere lombar permanent, mai accentuat nocturn, cu agravare progresiv. i-a administrat diverse AINS, iniial cu rspuns parial, cu minim efect n ultimele sptmni. Asociat acuz inapeten i scdere n greutate.

Istoric de neoplasm uterin operat n urm cu 1 an.Consultul periodic oncologic (august 2013) examen ginecologic fr modificri; recomandare de consult ortopedic i neurologic.Consult balneologic (august 2013) radiografie lombosacrat, care a fost fr modificri patologice semnificative; diagnosticat cu discopatie lombar, se recomand continuarea tratamentului cu AINS.

n ultimele 2 sptmni a prezentat durere lombar de intensitate foarte mare, cu iradiere n membrul inferior stng, parestezii, tulburri de sensibilitate pe faa antero-lateral a gambei stngi i deficit motor progresiv.

Examen obiectiv: mers stepat, sensibilitate la palparea apofizei spinoase a vertebrei L5

A fost corect interpretarea lombalgiei ca fiind de cauz discal la aceast pacient?

Da

Nu

Nu tiu

Red flags- facei investigaii suplimentare !!

Red flagsCauza posibilInvestigaiiVrsta > 50 aniIstoric de cancerDurere nocturn progresivScdere n greutate neexplicatCancerRMNRadiografie LSTomografie computerizatVSHVrsta > 50 aniIstoric de osteoporozCorticoterapieTasare vertebralRadiografie LSTomografie computerizatFebraInfecie recentConsumator droguri ivSpondilodiscitaRMNVSH/CRP

Deficite neurologice la multiple sediiAnestezie n aRetenie urinar/incontinen fecalSindrom de coad de calRMNDurere iradiat n membru, (distribuie L4, L5, S1), cu durata > 1 lunDeficit motor semnificativ/progresivHernie de disc RMNElectromiografie (EMG/VCN)Durere lombar joas inflamatoareVrsta < 45 aniSpondilita anchilozantaRMN art. SIRadiografie bazinVSH/CRP/HLA B27

Care este investigaia imagistic cea mai util ?

Tomografia computerizat

RMN

Scintigrafia osoas

Metastazele vertebraleMetastazele vertebrale sunt frecvente la pacienii cu cancer

Manifestri clinice Lombalgie mecanicSindrom radicularSindrom de compresie medular (!! URGEN)

Durerea este persistent i progresivDurerea nocturn este simptomul cu prognosticul cel mai nefavorabil

!! Recunoatei semnalele de alarm red flags i evitai ntrzierile de diagnostic

Investigaii n metastazele vertebrale

Examenul radiologicDistrucia corpului vertebral este vizibil radiologic doar cnd 30-50% din trabeculele vertebrale sunt afectateRadiografia normal NU EXCLUDE diagnostiul de metastaze !Scintigrafia osoas (screening)Tomografia computerizatRMN cu substan de contrast (gadolinium) = standardul de aurRMN lombosacrat, secven T2

Radiografie lombosacratThe winking owl sign

Suspiciunea de tasri vertebrale- Cine ? Unde ? Cnd?

Tasare vertebral osteoporotic

Tasare vertebral malign ReumatologNeurochirurg

ReumatologOncologNeurochirurg

ConcluziiDiagnosticul diferenial al durerii lombare se bazeaz n principal pe o anamnez comprehensiv, care sa includ evaluarea factorilor clinci care sugereaz existena unei patologii serioase (red flags) i a factorilor de risc pentru cronicitate (yellow flags), coroborat cu un examen obiectiv intit.

La majoritatea pacienilor cu durere lombar comun (nespecific) nu se poate stabili o cauz precis i nu sunt necesare investigaii suplimentare.

n prezena factorilor clinici care sugereaz existena unei patologii serioase (red flags), se recomand efectuarea de investigaii suplimentare, n principal imagistice.

The first rule of beach safety is: Always swim between the flags

The group of conditionsknown as rheumatic diseases, or musculoskeletal(MSK) disorders, is indeed an elephant, given the magnitudeof their impact on the population.As with the elephant as pictured by the blindman3, there are a number of ways to describe the effects ofhealth conditions in the population. There is the bean-countingapproach: determining how many people are affectedThey significantly affect the psychosocial status of the individuals with the condition as well as their families and carers.

Una dintre cele mai frecvente afectiuni cu care se intalneste medicul de familie si specialistul internist

The cervical region is the most mobile part of the spine. It is a complex structure and its mobilityand congruence are maintained by a multiplicity of structures, all of which can cause pain.It consists of seven vertebrae joined by intervertebral disks and by the joints between the articularprocesses of adjacent vertebrae facet joints.The atlanto-axial joint, C1C2, is very special. The vertebral body in the atlas (C1) is replacedby a bony arch, whose posterior face articulates with the odontoid process of the axis, whichprojects upward from the body of this bone (C2) (Figure 7.2.). A fibrous band, the transverseligament of the atlas, keeps the odontoid process of the axis congruent with the ring of the atlas (Figure 7.3.). This forms a synovial joint. The spinal cordis immediately behind this joint and can therefore bereadily affected by local instability

Between the spinal vertebrae are discs, which function as shock absorbers and joints. Each disc consists of a strong outer ring of fibers called the annulus fibrosis, and a soft center called the nucleus pulposus, The facet joints connect the bony arches of each of the vertebral bodies. There are two facet joints between each pair of vertebrae, one on each side. Facet joints connect each vertebra with those directly above and below it, and are designed to allow the vertebral bodies to rotate with respect to each other. The facet joints connect the bony arches of each of the vertebral bodies. There are two facet joints between each pair of vertebrae, one on each side. Facet joints connect each vertebra with those directly above and below it, and are designed to allow the vertebral bodies to rotate with respect to each other.

The cervical roots emerge from the spine through theintervertebral foramina, which are delimited anteriorlyand internally by the intervertebral disk and posteriorlyand externally by the facet joints (Figure 7.4.). Changesin the form or stability of these structures can cause irritationand compression of the nerve routes, resulting inneurogenic pain.The cervical nerve roots are responsible for the innervationof the scalp overlying the posterior aspect of thehead and the whole surface of the shoulder and upperlimb If you stare at computer screen all day, chances are youre suffering some kind of consequence from.Neck and arm pain related to texting is a growing phenomenon. Initially referred to as BlackBerry thumb, the repetitive stress that comes from excessive use of a wireless devices tiny keyboard to send text messages has been found to strain muscles, tendons, and ligaments in the hand, arm and neck. In addition, prolonged flexed-neck posture, or hunching over, as the keyboard is manipulated can cause cervical nerve disruption accompanied by acute or chronic neck pain. This non-traumatic pain often radiates down the arm causing a combined pain that is greater that arm or neck pain alone. Similar outcomes have long been associated with using a computer keyboard.It is predicted that if excessive texting behavior continues unabated, the number of nerve-related disorders such as osteoarthritis and degenerative disc disease will increase and lead to a debilitating pain syndrome that negatively impacts school and/or work performance. A more immediate concern is that inflammation of the basal joint at the base of the thumb due to excessive texting will result in thumb arthritis. This condition manifests itself in hand pain, swelling, decreased strength and limited range of motion.

. (A)Una dintre cele mai frecvente afectiuni cu care se intalneste medicul de familie si specialistul internist

*Incidenta inalta a anomaliilor RMN acestea nu determina intotdeauna durereRecomandm RMN ? DA - la pacienii cu simptome severe care nu rspund la tratament conservator n 6-8 sptmni se recomand RMN pentru a confirma dac exist o hernie de disc.

*MRI is highly sensitive and specific in detecting sacroiliac joint inflammation before damage can be detected by conventional radiographic techniques.1,2 It has the unique ability to illuminate early inflammatory changes in the spine and other structures including joint spaces, joint capsules, entheses, ligaments, subchondral bone and bone marrow.3 Because MRI is expensive and results can be ambiguous, it is currently reserved as a final diagnostic step for patients with additional AS characteristics.4 Although a highly sensitive test for sacroiliitis, there are still several years of delay after onset of symptoms which may lead to delayed diagnosis.References1. Sieper J, Rudwaleit M. Early referral recommendations for ankylosing spondylitis (including pre-radiographic and radiographic forms) in primary care. Ann Rheum Dis. 2005;64:659-663.2. Rudwaleit M, Khan MA, Sieper J. The challenge of diagnosis and classification in early ankylosing spondylitis: Do we need new criteria? Arthritis Rheum. 2005;52:1000-10083. Bollow M, Braun J. Enthesophytes develop by endochondral ossification in enthesis fibrocartilage and their formation can be an extension of normal enthesis development: detailed MRI assessments of the axial skeleton in spondyloarthropathy. Ann Rheum Dis. 2000;59:995.4. Rudwaleit M, van der Heijde D, Khan M, Braun J, Sieper J. How to diagnose axial spondyloarthritis early. Ann Rheum Dis. 2004;63:535-543.*Currently, there is a long delay, from 5 to 10 years, between the first occurrence of AS symptoms and a diagnosis of AS. Two major reasons can be named for such a delay: There is certainly a low awareness of AS among nonrheumatologists and it can be seen as a major challenge for any physician in primary care to think of and to identify patients with inflammatory spine disease among the large group of patients with chronic back pain, most often of another origin. (b) Radiographic sacroiliitis grade 2 bilaterally or grade 3 or 4 unilaterally is usually a requirement for making the diagnosis of AS according to the modified New York criteria.

However, radiographic changes indicate chronic changes and damage of the bone and are the consequence of inflammation and not active inflammation itself. Since AS is a slowly progressing disease as far as radiographic changes are concerned, definite sacroiliitis on plain radiographs appears relatively late, frequently taking several years of continuous or relapsing inflammationConceptul nou introdus al SpA axiale postuleaz c n SA exist un stadiu pre-radiologic n care leziunile precoce de la nivelul articulaiilor sacroiliace nu pot fi vizualizate radiologic, dar poate fi detectat edemul osos prin examenul RMN. Se presupune c aceste leziuni inflamatorii evideniate prin RMN preced leziunile structurale ce vor aprea ulterior la examenul radiologic. Pe de alt parte, nu se tie dac toi pacienii cu SpA axial precoce vor evolua spre o SA definit i nici care este valoarea prognostic a leziunilor detectate prin RMN. The ASsessment in AS (ASAS) working group together with the European League Against Rheumatism (EULAR) have developed evidence-based recommendations for the management of AS. With disease progression moving vertically from top to bottom, this figure emphasises the importance of nonpharmacological treatments throughout the course of the disease, early introduction of NSAIDs and options for refractory disease and alternatives for concomitant peripheral disease including TNF inhibitors.ReferenceZochling J, van der Heijde D, Burgos-Vargas R, et al. ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis. 2006;65:442-452.

The T1-weighted Sagittal demonstrates multifocal metastatic tumor. A mild to moderate compression fracture of L1 is visible with preservation of normal marrow signal dorsally (asterisks). If this were an isolated fracture in a patient with a history of acute trauma, its imaging appearance might create some uncertainty. Note that there is slight convexity of the posterior cortex of L1 (arrow) despite adjacent "normal" appearing marrow.

One of the most reliable signs of osteolytic spinal metastases on conventional radiographs is the loss of vertebral pedicle contours on AP views of the thoracic or lumbar spine. This sign of the absent pedicle has also been termed the winking owl sign, where the missing pedicle corresponds to the closed eye, the contralateral pedicle to the other open eye, and the spinous process to the beak of the animal.

neck and low back pain

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